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Published on: April 7, 2021
Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a
Christopher J L Newth1, Katherine A Sward, Robinder G Khemani
11Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. 2Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA. 3University of Utah College of Nursing, Salt Lake City, UT. 4Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT. 5Department of Pediatrics, Division of Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT. 6Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI. 7Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 8Department of Pediatrics, University of Michigan, Ann Arbor, MI. 9Department of Child Health, Phoenix Children's Hospital, Phoenix, AZ. 10Department of Pediatrics, Children's National Medical Center, Washington, DC. 11Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA. 12Department of Pediatrics, Mattel Children's Hospital, UCLA, Los Angeles, CA. 13Departments of Pediatrics and Biochemistry, Washington University School of Medicine, St. Louis, MO. 14Pediatric Trauma and Critical Illness Branch, National Institutes of Child Health and Human Development (NICHD), Bethesda, MD. 15Formerly Pediatric Trauma and Critical Illness Branch, National Institutes of Child Health and Human Development (NICHD), Bethesda, MD.
Objectives:
Although pediatric intensivists philosophically embrace lung protective ventilation for acute lung injury and acute respiratory distress syndrome, we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry, or end-tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation protocol adapted from National Heart Lung and Blood Institute acute respiratory distress syndrome network protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol.
Design:
Prospective observational study.
Setting:
Eight tertiary care U.S. PICUs, October 2011 to April 2012.
Patients:
One hundred twenty patients (age range 17 d to 18 yr) with acute lung injury/acute respiratory distress syndrome.
Measurements And Main Results:
Two thousand hundred arterial and capillary blood gases, 3,964 oxygen saturation by pulse oximetry, and 2,757 end-tidal CO2 values were associated with 3,983 ventilator settings. Ventilation mode at study onset was pressure control 60%, volume control 19%, pressure-regulated volume control 18%, and high-frequency oscillatory ventilation 3%. Clinicians changed FIO2 by ±5 or ±10% increments every 8 hours. Positive end-expiratory pressure was limited at ~10 cm H2O as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of mechanical ventilation, maximum tidal volume/kg using predicted versus actual body weight was 10.3 (8.5-12.9) (median [interquartile range]) versus 9.2 mL/kg (7.6-12.0) (p < 0.001). Intensivists made changes similar to protocol recommendations 29% of the time, opposite to the protocol's recommendation 12% of the time and no changes 56% of the time.
Conclusions:
Ventilator management varies substantially in children with acute respiratory distress syndrome. Opportunities exist to minimize variability and potentially injurious ventilator settings by using a pediatric mechanical ventilation protocol offering adequately explicit instructions for given clinical situations. An accepted protocol could also reduce confounding by mechanical ventilation management in a clinical trial.
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